A daily diary examination of the influence of intersectional stigma on blood pressure

Hypertension is the most important modifiable risk factor for cardiovascular disease (CVD), the leading cause of death and disability in adults worldwide. Stigmatized populations, such as people of color and sexual minority (e.g., gay/lesbian, bisexual) adults, have a higher prevalence of hypertension that is primarily attributed to greater exposure to stigma; a fundamental cause of health disparities. However, prior research on the effects of stigma on blood pressure (BP) has largely focused on enacted stigma (i.e., personally experienced discrimination) to the exclusion of other forms of stigma, such as anticipated (i.e., expectation of encountering discrimination) and vicarious (i.e., hearing/witnessing people like you being the target of discrimination) stigma. Most research in this area has focused on stigma due to a single stigmatized identity; an approach that ignores and obscures the experiences of groups that face intersecting forms of stigma. Given these limitations, we posit that researchers have previously underestimated the impact of stigma on BP. We have compelling pilot data showing that, independent of enacted stigma, greater report of daily intersectional anticipated stigma (attributed to any reason, such as race or sexual identity) is associated with higher home systolic BP (SBP; a stronger predictor of future CVD events than in-office SBP) among stigmatized adults. The overall goal of this 1-week daily diary study is to estimate the influence of intersectional anticipated and vicarious stigma on home BP. We will conduct the first study that triangulates robust methods to examine mechanisms linking daily and chronic anticipated and vicarious stigma with BP in individuals’ real-world environments. We will recruit a diverse sample of 400 adults (ages 18–39) without diagnosed hypertension or CVD. Participants will complete a structured interview followed by 1 week of twice-daily structured electronic diaries that will assess daily anticipated, vicarious, and enacted stigma, collection of saliva samples to assess salivary stress biomarkers, continuous wrist-worn actigraphy, and twice daily home BP monitoring. We will: 1) Determine the influence of intersectional anticipated and vicarious stigma on mean home SBP and mediators of these associations (e.g., salivary cortisol, physical activity, rumination) and 2) Examine differences in intersectional anticipated and vicarious stigma and mean home SBP across social identities (i.e., gender, ethnoracial, and sexual identity) and the intersections between them. We will also explore whether protective factors (i.e., social support and subjective social status) buffer (i.e., weaken) the influence of intersectional anticipated and vicarious stigma on mean home SBP. This study will provide the first evidence of mechanisms by which anticipated and vicarious stigma influence BP. If we find that anticipated and/or vicarious stigma influence BP—even in the absence of enacted stigma—it will shift how we think about the design of interventions for CVD risk reduction among stigmatized adults. This study is a critical step for identifying mechanistic targets for future interventions and policies to reduce the adverse effects of anticipated and vicarious stigma on cardiovascular health.